Sample - Home Health Consulting - PN Systempnsystem.com/images/Clinical_Forms.pdf · CARDIOVASCULAR...

PATIENT REFERRAL INFORMATION Med. Record _________________________HIC ________________________ SOC ______________ CERT PERIOD_____________________________________PATIENT NAME _________________________________________________________________________________EFFECTIVE DATE: _______________ DOB ___________________ SEX ______ MARITAL STATUS ___________ REF. TO: ______________________________ TEAM LEADER__________________________________________STREET _______________________________________________ PRIM. LANG. _____________________________CITY___________________________________ COUNTY ___________ STATE_______ ZIP __________________ PREVIOUS ADMIT ___________________ NON-ADMIT___________ TELEPHONE ( )___________________ 2ND TELEPHONE ( )_____________________ LIVES WITH __________________________________________ EMERGENCY ___________________________________________ CAREGIVER ___________________________Relation: _________________________ phone: _________________ 9 Medicare 9 Medicaid 9 Other ___________DIAGNOSIS:ICD-9CM __________ PRINCIPAL DIAGNOSIS ____________________________________DATE ____________ICD-9CM __________ SURGICAL PROCEDURE ___________________________________ DATE ____________OTHER PERTINENT DIAGNOSIS:ICD-9CM __________ OTHER DIAGNOSIS ________________________________________DATE ____________ICD-9CM __________ OTHER DIAGNOSIS ________________________________________DATE ____________ICD-9CM __________ OTHER DIAGNOSIS ________________________________________DATE ____________ICD-9CM __________ OTHER DIAGNOSIS ________________________________________DATE ____________Past Medical Hx:__________________________________________________________________________________________________________________________________________________________________________________

Wound/Decubitus/Dressing:

Location Size Color Drainage Treatment

MEDICATIONS STRENGTH DOSAGE FREQUENCY ROUTE N/C

DME Company __________________________________ Nutritional Status ____________________________________________Equipment ______________________________________ 9 G-Tube 9 Ng-TubeSafety Measures: _________________________________ Allergies:__________________________________________________Initial Verbal MD Order Date _______________________ Last M.D. Visit____________________________ 9 Face to Face donePhysician’s Name: _____________________________________________ Phone: ( ) ____________________________________Street Address ___________________________________ City, State, ZC: _______________________________________________License:_________________ 9 Verified Medipass:_____________ Upin: ________________ NPI: _______________________

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PATIENT REFERRAL INFORMATION

PATIENT NAME _____________________________________ Med. Record ______________ SOC _____________

FUNCTIONAL LIMITATIONS: ACTIVITIES PERMITTED:

__ Amputation __ Ambulation ___ Complete bed rest ___ Indep. & home__ Bowel/Bladder Inct. __ Speech ___ Bed Rest BRP ___ Crutches__ Contracture __ Legally blind ___ Up as tolerate ___ Cane__ Hearing __ Dyspnea ___ Transfer bed/chair ___ Wheelchair__ Paralysis w/min exertion ___ Exercise Prescribed. ___ Walker__ Endurance __ Other (specify) ___ Partial Wt. Bear ___ No Restrictions

Homebound Status: ______________________________________________________________________________________________________________________________________________________________________________

MENTAL STATUS: ____Alert ___ Oriented ___ Disoriented ___ Lethragic ___ Forgetful ___ Comatose ____ Depressed ___ Anxious ___ Agitated

PROGNOSIS: ___ Poor ___ Guarded ___ Fair ___ Good ___ Excellent

Vital Signs (if applicable): B/P________ P ________ R _________ T _________ Weight ________ Ht __________Pharmacy ______________________________________________________ Telephone ( ) ___________________Foley Cath (Y) (N) if (Y) Date inserted ___________________________Lab Work ___________________________________________ Frequency __________________________________

DISCIPLINE NAME FREQUENCYSign Up ___________________________________ __________________________________________

(SN)Follow-Up _____________________________ __________________________________________

HHA ____________________________________ __________________________________________

PT ____________________________________ __________________________________________

MSW _____________________________________ __________________________________________

OTHER ___________________________________ __________________________________________Referral SourceHospital __________________________ Medical Office _____________________________ Other_______________

Admission _____________________ D/C Date ___________________

Preferred Hospital Name _________________________________ Other Agency involved _______________________

OTHER INSURANCE: Y ____ N ____Name of Insured __________________________________________________________________________________SS # _______________________________ Ins. Co.: ____________________________________________________Address ____________________________________ City: __________________ State: ________ Zip ____________Phone: ( ) _______________________ Policy #: _________________________ Group # ______________________

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COMPREHENSIVE ADULT NURSING ASSESSMENTWITH CMS 485 (POC) INFORMATION

/DATE

TIME OUTTIME IN(M0030) Start of Care Date:

Provider Number:

Emergency/Disaster Plan Classification Code:

PATIENT NAME - Last, First, Middle Initial Med. Record #

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Agency Name:________________________________________

Employee's Name/Title Completing the Assessment:

_____________________________________________________________

Physician name: _______________________________

Address: ___________________________ _________________________________________Phone Number: ______________________________

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Other Physician (if any): _______________________________


Patient ID Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ (Medical Record)

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Patient Name:____________________________________________...Address: _____________________________________________________.. _____________________________________________________..Patient Phone: __________________________

Social Security Number:_________________

Medicaid Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ Birth Date: __ __ /__ __ /__ __ __ __ Gender: Male Female month / day / year

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Certification Period:From __/___/ To / / /

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19EMERGENCY CONTACT:

Address:Phone: Relationship:OTHER:

6REFERRAL SOURCE (if not from Primary Physician):

Phone:

Evacuation Form needed? Emergency Registration Completed (please document)

Fax:

PHYSICIAN: Date last contacted: Date last visited: Reason:

Phone:

7

ALF / AFHC (circle)

Name:

Phone:

PT ID PERFORMED VIA NAME, DOB, FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED

POC (CMS - 485) Box#

SG Safety Goal

/ / / /

SG

Referral date: / /N/A

CHIEF COMPLAINT:

PRESENT ILLNESS/NURSING DIAGNOSIS:

NoRECENT HOSPITALIZATION? Yes, datesReason:

Yes, specifyN oNew diagnosis/condition?

PERTINENT HISTORY AND/OR PREVIOUS OUTCOMES:

Fractures: _______OsteoporosisRespiratoryCardiacHypertension

InfectionOpen WoundImmunosuppressed

Cancer (site: )

Other:Surgeries:

-

Up-to-dateIMMUNIZATIONS:Tetanus Other (specify)Needs: Influenza PneumoniaH1N1

ICD-9-CM Primary & Other Diagnosis

Date //)(

Date / /)(

1212

Date //)(

Date / /)(

Date //)(

Date / /)(ICD-9-CM Surgical Procedure

Date //)(

Date / /)(

1212

PREVIOUS OUTCOMES:

DiabetesInsulin DependentNon Insulin Dependent

DIAGNOSIS:

VITAL SIGNS: Blood Pressure: Sitting/lying RLStanding R

LOral Axillary

Temperature:

Rectal Tympanic

Rest ActivityCheynes Stokes

Death rattleRespirations:

Apnea periods -sec.Accessory muscles usedRegular Irregular

Regular Irregular

Pulse: BrachialApicalRadial Carotid

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CARDIOVASCULAR

SYSTEM REVIEWLocalizedPostural SubsternalChest pain: Anginal

Vise-like Dull AcheSharpRadiatingAssociated with: ActivitySOB Sweats

Glaucoma JaundiceGlasses Frequency/durationContacts: R / L PtosisBlurred vision Other (specify)Prosthesis: R / L Legally blind Palpitations: Nocturnal/Persistent/intermittent

EYES Infections Other (specify)DateCataract surgery: Site / / Heart rate: Regular Irregular Reg./Irreg.

Other (specify, incl. hx) Orthostatic hypotension Syncope VertigoNO PROBLEM BP (specify)Reg. Irreg. (specify)Heart sounds:Deaf: R / L Hearing aid: R/LHOH: R / L

Pulse deficit (specify)

EAR

S TinnitusVertigo Dependent:Edema: Pedal R/LOther (specify, incl. hx) Non-pitting (site)Pitting +1/+2/+3/+4NO PROBLEMClaudication: R calf/L calf/Night changes

HEAD/NECK JVD FatigueHeadache( see Neurological section)

RxThrombus: SiteInjuries/Wounds ( see Skin Condition/Wound section)Cramps: LE/UE/Night (site)Masses/Nodes: Site SizeCyanosis (site)AlopeciaCap refill: 3 sec.Other (specify, incl. hx)Pulses: LDP/LPT/RDP/RPTNO PROBLEMPacemaker: Date Type/ /NOSE/THROAT/MOUTH Other (specify incl. hx)

HoarsenessCongestion Epistaxis DysphagiaLesions Sore throatSinus prob.Loss of smell

NO

SE Other (specify, incl. hx)Other (specify, incl. hx)

NO PROBLEMRESPIRATORY STATUSClear Crackles Wheeze AbsentBreath sounds:NO PROBLEMNO PROBLEM

Cough: Dry/Acute/ChronicDentures: Upper /Lower /Partial Masses/Tumors Productive: Thick/Thin/Difficult Color

MO

UTH Ulcerations ToothacheGingivitis Smoker: packs/day X years

Other (specify, incl. hx)Exertion: amb. feetRestDyspnea:

during ADLsNO PROBLEMOrthopnea: # of pillows

ENDOCRINE Fremitus: LocationCrepitus/Amt.Hemoptysis: FrequencyIntolerance to heat/coldEnlarged thyroid Fatigue

Barrel chestDiabetes: Type I/Type II Onset / / Skin temp/color changemos. yearsDiet/Oral control X

Percussion: Resonant/Tympanic/Dull

Med./dose/freq.Ant.R Lat. Post.Chart lobe: L;

Insulin/dose/freq.Hyperglycemia: Glycosuria / Polyuria / Polydipsia 02 Sat.Hypoglycemia: Sweats/Polyphagia/Weak/Faint/Stupor Mask Nasal Trach02 use: L/rnin. byBlood Sugar RangeSelf-care/Self-observational tasks (specify)

ConcentratorLiquidGas

Other (specify, incl. hx)Other (specify, incl. hx)

NO PROBLEMNO PROBLEM

Med. Record #PATIENT/CLIENT NAME - Last, First, Middle Initial

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Oxygen Precaution/Fire Prevention followed/explained to patient SG

5-Excellent3-Fair 4 Good1- Poor 2- Guarded

PROGNOSIS: 20

Nose surgery:

Any mouth surgery/procedure:

FUNCTIONAL LIMITATIONS7-Ambulation1 -Amputation

2-Bowel/Bladder 8-Speech(incontinence)9-Legally blind3 - Contracture

A -Dyspnea with 4-Hearing

B- Other (specify)

5-Paralysis 6-Endurance

18A

Dizziness

Generalized WeaknessArthralgia

InsomniaHeadache

AnxietySOB on exertion

Heartburn

Poor vision

Productive cough

Unsteady GaitPain on ambulation

Varicositis on lower ext.Edema in __________

Legs weak

Chest pain on exertionFatigues at times

Decreased Bil. breath soundsBack Pain

PalpitationsLimited MobilityLimited ROMLeg crampsFreq. Coughing episodesNeeds assistance of 1 person

HOMEBOUND REASON:

Needs assistance for all activities (ADL's)

Requires assistance to ambulate/Decreased Range of MotionGeneralized Weakness

Confusion, unable to go out of home alone

Severe SOB, SOB upon exertion, amb. ____ feet

Unable to safely leave home without assistance

Medical restrictions

Dependent upon adaptive device(s)

(Mark all that apply):

Other (specify):

Needs assist of 1-2 persons

Bedbound (Partial/Complete)

Mobility/Ambulatory device(s) used:

Unsteady Gait

18A

GENITOURINARY STATUS

(Check all that apply:) Nocturia xUrgency/frequencyBurning/pain Hesitancy Hematuria Oliguria/anuriaIncontinence: Urinary Bowel Diapers/other:

Blood-tingedColor: Yellow/straw Amber Brown/gray Other: Clarity: Clear Cloudy Sediment/mucousOdor: Yes No Urinary Catheter: Type Last changed on: Foley inserted (date) with FrenchInflated balloon with mL without difficulty Suprapubic Irrigation solution: Type (specify): Amount mL Frequency ReturnsPatient tolerated procedure well Yes No Urostomy (describe skin around stoma):

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NUTRITIONAL STATUS

GENITALIADischarge/Drainage: Urine/Vag. mucus/FecesLesions/Blisters/Masses/Cysts Inflammation

Surgical alteration

NUTRITION HEALTH SCREEN

Prostate problem: BPH/TURP Date / /

Directions: Circle each area with ''yes'' to assessment, then total score

Self-testicular exam Freq.

to determine additional risk. YESHas an illness or condition that changed the kind and/or amount offood eaten. 2Eats fewer than 2 meals per day. 3Eats few fruits, vegetables or milk products. 2Has 3 or more drinks of beer, liquor or wine almost every day. 2Has tooth or mouth problems that make it hard to eat. 2Does not always have enough money to buy the food needed. 4Eats alone most of the time. 1Takes 3 or more different prescribed or over-the-counter drugs a day. 1Without wanting to, has lost or gained 1 0 pounds in the last 6 months. 2Not always physically able to shop, cook and/or feed self. 2

TOTAL

Menopause: DateHysterectomy / /Date last PAP Results/ /

Breast self-exam. freq. Discharge: R/LMastectomy: R/L Date / /Other (specify incl. hx)

NO PROBLEM

HEMATOLOGY/ IMMUNEAnemia: Iron deficient/Pernicious 2o Bleed: GI/GU/GYN/Unknown

Ablastic/Hemolytic/PolycythemiasThrombocytopenia Coagulation disordersHemophilia, other

INTERPRETATION

Malignancies (specify):

0-2 Good. As appropriate reassess and/or provide information based on situation.3-5 Moderate risk. Educate, refer, monitor and reevaluate based on patient

Prior RxComplications

situation and organization policy.

Other (specify, immunological problem)

6 or > High risk. Coordinate with physician, dietitian, social service professionalor nurse about how to improve nutritional health. Reassess nutritional status andeducate based on plan of care.

NO PROBLEM

NEUROLOGICALOriented X

NO PROBLEMReprinted with permission by the Nutrition Screening Initiative, a project of the American Academy ofFamily Physicians, the American Dietetic Association and the National Council on the Aging, Inc., andfunded in part by a grant from Ross products Division, Abbott Laboratories Inc.

Insomnia/Change in sleep patternSlurred speech

ELIMINATION STATUS

SyncopeVertigoSensory lossAtaxia

Usual frequencyLast BM / /

NumbnessHx of frequent falls

>3x/day

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SAFETY MEASURES

Origin:

OnsetLocation

Quality (i.e., burning, dull ache)Intensity level: 0 1 2 3 4 5 6 7 8 9 10Freq./Duration

Aggravating/Relieving Factors:

Pain Management History

SKIN CONDITION/WOUNDS/LESION

Present Pain Management Regimen

Effectiveness

Sutures Staples

Turgor: Good Poor

Other (specify)

NO PROBLEM

Edema: Lymph Hema.Other (specify, incl. pertinent hx)

APPLIANCES/AIDS/SPECIAL EQUIPMENT:Wheelchair

Cane WalkerCrutch(es)

NO PROBLEM

Other (specify):

Denote location of specific skin conditions/wounds by numberingappropriately on illustrations below.

Prosthesis: Hospital bed

Oxygen: HME Co.

Phone:

Fire Alarm Smoke Alarm

Size (cm)Depth

MUSCULOSKELETALFracture (location)Swollen, painful joints (specify)

LocationContractures: JointPoor conditioningAtrophyParesthesiaDecreased ROM

Shuffling/Wide-based gait WeaknessAmputation: BK/AK/UE; R/L (specify)

QuadriplegiaParaplegiaHemiplegiaOther (specify, incl. pertinent hx)


#ICONDITION #2 #3 #4

Safety Measures: CMS485 (POC)Cast PrecautionsChange position slowlyCoumadin/Heparin PrecautionsDo not lift, bend, stoopGood handwashing techniqueOxygen Precaution/Fire preventionPractice Universal Precautions

15

Safe Ambulation

Respiratory PrecautionsDiabetic PrecautionsWound/Decubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries G.I. Precautions

Prev. Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storage/disposal syringes Cardiac Precautions

G.U. Precautions

Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan

Maintain Safe/clear EnvironmentMaintain Good Skin care

Clear pathways

Other:

SG

Correct handwashing technique SGCheck bathroom, floor/stairs for safety hazards

SG

PAIN MANAGEMENTItch Rash Dry Scaling Incision Wounds LesionsDecubitus Fistulas Abrasions LacerationsBruises Ecchymosis Pallor: Jaundice Redness

Stage

Drainage/Amt.

TunnelingOdor

Sur. Tis.Edema

Stoma

None known / NKA AspirinSulfaPollens and mold spores

EggsPenicillin

Insect bitesDairy/Milk products

Other

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Iodine Dust mitesAnimal dander and urine

ALLERGIES

Lifts Bedside Commode

Patient is prone to FALL: Yes:NoFall risk assessment conducted every_______________Fall prevention program in place, patient instructed SG

Comment:

HOME ENVIRONMENT SAFETYSafety hazards in the home: (check all that apply)

NYFire alarm/smoke detector /Fire extinguishInadequate heating/ cooling/ electricity / lightingHurricane, Disaster Emergency supplies/kits

NYY N

NYFirst aid box/Emergency Equipment or SuppliesNYUnsafe gas/electrical appliances or electrical outletsNYInadequate running water, plumbing problemsNUnsafe storage of supplies/ equipment/ HME

No telephone available and/or unable to use the phonePest problems, Insects/rodentsMedications stored safely, clearly-easy use

NYNYNY

Emergency planning, Exit Plan in place, more than one exit Y NNYEnough Ventilation

Safe Beds/Chairs, clear pathwaysY NAble to follow directions in case of Emergency

NYSlippery Floors, Ashtrays (if a smoker)NYPlan for power failure, emergency lights, flashlights, etc.

Y

NY

NYRelevant medical appliances, if applicable ( wheelchair, O2, Monitors, etc.)NYHurricane Shutter , Disaster Plan

ENTERAL FEEDINGS - ACCESS DEVICE - IVNasogastric Gastrostomy Jejunostomy Feeding type:

Pump: (type/specify) Bolus Continuous

TPNDevice: IV:

N/AFinancial ability to pay for medications/insurance covered: Yes NoComment:

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ACTIVITY PRIOR Level of Function I A D COMMENTS (who assists, assistive device used, etc.)Eating/Kitchen accessTransfer abilitiesDressing/GroomingBathing/ Personal CareToileting/Hygiene abilitiesAmbulation/ROMCommunication (verbal, non-verbal)Preparing/Serving light mealsPreparing full mealsLight housekeepingPersonal laundryHandling moneyUsing telephoneReading,

Managing MedicationsOther (Specify)

ACTIVITIES OF DAILY LIVING (Legend: I-Independent; A-Assist; D-Dependent)

G O A L S

DISCHARGE PLANS

Yes NoDiscussed with patient/client?

NoYesDRUG REGIMEN REVIEW COMPLETED?PATIENT/CLIENT/CAREGIVER RESPONSE

ISUMMARY CHECKLIST SIGNATURES/DATESx / /

PatientlClientlCaregiver (optional if weekly is used) Date

/ /Nurse signature/title Date

PRN order obtainedOrder obtainedNo changeMEDICATION STATUS:Yes NoMEDICATION SCHEDULE/RECORD FILL OUT?

PT OT S T MSWPhysicianCARE COORDINATION:SN Aide Other (specify)

PATIENT/CLIENT NAME - Last, First, Middle Initial Med. Record #

2.3.4.

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WritingHair care, Skin Care

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RefusedIndications for Home Health Aide may be needed:

NoYesMD Order obtained:

OTSN MSWOther Services ordered: STPT Comment:

If the patient experiment:-ADL/IADL Deficit - Elimination Deficit - Impaired Mobility:

Patient/Family:

N/A (Home Health Aide Services not needed)

SKILLED NURSING INTERVENTION/SERVICE

Instructions/Information Provided (Check all that apply):

Patient Rights and responsibilitiesState hotline/ABUSE numberAdvance directives information

Do not resuscitate (DNR) (if applicable)Service Agreement/ContractOASIS/HIPAA Privacy Notice, Confidentiality

Emergency Plan, classification, instructionsAgency phone numbers, addressClient Information Handbook

Standard precautions /handwashing/ Infection Control

Home safety guidelines

Admission criteria, Information for Home visit, Services, FrequencyDiabetes Control, other disease management information

Other

Medication sheet, instructions

Alzheimer's, Fall prevention, Sensory impairments info

Care Plans

Pain Management info Grievance Procedures

Local Resources Guide Mission, ownership information

Skilled Observation / AssessmentINJECTION ROUTE:_______ SITE: _____ MED. GIVEN: ______________________ DOSE: __________ REACTION: _____________________________

Foley Change/Care Patient Education/teaching Wound Care / Dressing Change Prep. / Admin. Insulin

Standard/Universal Precautions Followed Aseptic Tech. Used. Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container

Procedure/Tx welltolerated by Pt.

Diabetic Observation / Care

Correct handwashing technique followed SG Management/Evaluation Patient's Care Plan No caregiver/family available/willing to help patient with care, procedures.

SN or ______ - ORDERS - FREQUENCY/DURATION:21AIDE - ORDERS - FREQUENCY/DURATION:

TUB/SHOWER BATH PERSONAL CAREHAIR COMBORAL HYGIENETPR

ASSIST TO DRESS

WASH CLOTHESLIGHT HOUSEKEEPING

ASSIST WITH PERSONAL CARE AND ADL'SPERI CARE

REPORT SIGNIFICANT FINDING TO AGENCY/CASE MANAGER

OTHER:

RETURN TO INDEPENDENT AMBULATION. BE SAFE IN SELF CARE.PATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HIS/HER CURRENT LIMITATIONS AT HOME.

GOOD/FAIR RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY.

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PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATIONS AT HOME.OTHER:

WILL DISCHARGE THE PATIENT WITHIN ____ WEEKS, WHEN PATIENT AND/ORCAREGIVER IS/ARE ABLE TO DEMONSTRATE PROPER CARE MANAGEMENT, NO S/S COMPLICATIONS.PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT HOME.OTHER:

REHAB POTENTIAL LEVEL:

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RECERTIFICATION COMPREHENSIVE ADULT NURSING ASSESSMENTWITH CMS 485 (POC) INFORMATION

/DATE

TIME OUTTIME IN(M0030) Start of Care Date:

Provider Number:

Emergency/Disaster Plan Classification Code:

PATIENT NAME - Last, First, Middle Initial Med. Record #

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Agency Name:________________________________________

Employee's Name/Title Completing the Assessment:

_____________________________________________________________

Physician name: _______________________________


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Other Physician (if any): _______________________________


Patient ID Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ (Medical Record)

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Patient Name:____________________________________________...Address: _____________________________________________________.. _____________________________________________________..Patient Phone: __________________________

Social Security Number:_________________

Medicaid Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ Birth Date: __ __ /__ __ /__ __ __ __ Gender: Male Female month / day / year

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Certification Period:From __/___/ To / / /

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1

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EMERGENCY CONTACT:Address:Phone: Relationship:OTHER:

6

Evacuation Form needed? Emergency Registration Completed (please document)

PHYSICIAN: Date last contacted: Date last visited: Reason:

Phone:

7

ALF / AFHC (circle)

Name:

Phone:

PT ID PERFORMED VIA NAME, DOB, FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED

POC (CMS - 485) Box#

SG Safety Goal

/ / / /

SG

CHIEF COMPLAINT:

ANY MODIFY ORDERS OR STATUS CHANGES FROM PREVIOUS EPISODE:

NoRECENT HOSPITALIZATION? Yes, datesReason:

Yes, specifyN oNew diagnosis/condition?

-

Up-to-dateIMMUNIZATIONS:Tetanus Other (specify)Needs: Influenza PneumoniaH1N1

ICD-9-CM Surgical Procedure

Date //)(

Date / /)(

1212

PREVIOUS OUTCOMES:

8

Any change from previous episode in Emergency Information: No Yes, update the following info:Complete new Emergency/Disaster form

What negative findings substantiate this Patient to be recertified?

Summary of the Services that need to be continued (State frequency, duration, amount):SNPTOT

MSWAide

Comment:

ICD-9-CM Primary & Other Diagnosis

Date //)(

Date / /)(

1212

Date //)(

Date / /)(

Date //)(

Date / /)(

DIAGNOSIS:

STOther:

Comment:Comment:Comment:

Comment:Comment:

Comment:

VITAL SIGNS: Blood Pressure: Sitting/lying RLStanding R

LOral Axillary

Temperature:

Rectal Tympanic

Rest ActivityCheynes Stokes

Death rattleRespirations:

Apnea periods -sec.Accessory muscles usedRegular Irregular

Regular Irregular

Pulse: BrachialApicalRadial Carotid

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CARDIOVASCULAR

SYSTEM REVIEWLocalizedPostural SubsternalChest pain: Anginal

Vise-like Dull AcheSharpRadiatingAssociated with: ActivitySOB Sweats

Glaucoma JaundiceGlasses Frequency/durationContacts: R / L PtosisBlurred vision Other (specify)Prosthesis: R / L Legally blind Palpitations: Nocturnal/Persistent/intermittent

EYES Infections Other (specify)DateCataract surgery: Site / / Heart rate: Regular Irregular Reg./Irreg.

Other (specify, incl. hx) Orthostatic hypotension Syncope VertigoNO PROBLEM BP (specify)Reg. Irreg. (specify)Heart sounds:Deaf: R / L Hearing aid: R/LHOH: R / L

Pulse deficit (specify)

EAR

S TinnitusVertigo Dependent:Edema: Pedal R/LOther (specify, incl. hx) Non-pitting (site)Pitting +1/+2/+3/+4NO PROBLEMClaudication: R calf/L calf/Night changes

HEAD/NECK JVD FatigueHeadache( see Neurological section)

RxThrombus: SiteInjuries/Wounds ( see Skin Condition/Wound section)Cramps: LE/UE/Night (site)Masses/Nodes: Site SizeCyanosis (site)AlopeciaCap refill: 3 sec.Other (specify, incl. hx)Pulses: LDP/LPT/RDP/RPTNO PROBLEMPacemaker: Date Type/ /NOSE/THROAT/MOUTH Other (specify incl. hx)

HoarsenessCongestion Epistaxis DysphagiaLesions Sore throatSinus prob.Loss of smell

NO

SE Other (specify, incl. hx)Other (specify, incl. hx)

NO PROBLEMRESPIRATORY STATUSClear Crackles Wheeze AbsentBreath sounds:NO PROBLEMNO PROBLEM

Cough: Dry/Acute/ChronicDentures: Upper /Lower /Partial Masses/Tumors Productive: Thick/Thin/Difficult Color

MO

UTH Ulcerations ToothacheGingivitis Smoker: packs/day X years

Other (specify, incl. hx)Exertion: amb. feetRestDyspnea:

during ADLsNO PROBLEMOrthopnea: # of pillows

ENDOCRINE Fremitus: LocationCrepitus/Amt.Hemoptysis: FrequencyIntolerance to heat/coldEnlarged thyroid Fatigue

Barrel chestDiabetes: Type I/Type II Onset / / Skin temp/color changemos. yearsDiet/Oral control X

Percussion: Resonant/Tympanic/Dull

Med./dose/freq.Ant.R Lat. Post.Chart lobe: L;

Insulin/dose/freq.Hyperglycemia: Glycosuria / Polyuria / Polydipsia 02 Sat.Hypoglycemia: Sweats/Polyphagia/Weak/Faint/Stupor Mask Nasal Trach02 use: L/rnin. byBlood Sugar RangeSelf-care/Self-observational tasks (specify)

ConcentratorLiquidGas

Other (specify, incl. hx)Other (specify, incl. hx)

NO PROBLEMNO PROBLEM


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Oxygen Precaution/Fire Prevention followed/explained to patient SG

5-Excellent3-Fair 4 Good1- Poor 2- Guarded

PROGNOSIS: 20

Nose surgery:

Any mouth surgery/procedure:

FUNCTIONAL LIMITATIONS7-Ambulation1 -Amputation

2-Bowel/Bladder 8-Speech(incontinence)9-Legally blind3 - Contracture

A -Dyspnea with 4-Hearing

B- Other (specify)

5-Paralysis 6-Endurance

18A

Dizziness

Generalized WeaknessArthralgia

InsomniaHeadache

AnxietySOB on exertion

Heartburn

Poor vision

Productive cough

Unsteady GaitPain on ambulation

Varicositis on lower ext.Edema in __________

Legs weak

Chest pain on exertionFatigues at times

Decreased Bil. breath soundsBack Pain

PalpitationsLimited MobilityLimited ROMLeg crampsFreq. Coughing episodesNeeds assistance of 1 person

HOMEBOUND REASON:

Needs assistance for all activities (ADL's)

Requires assistance to ambulate/Decreased Range of MotionGeneralized Weakness

Confusion, unable to go out of home alone

Severe SOB, SOB upon exertion, amb. ____ feet

Unable to safely leave home without assistance



(Mark all that apply):

Other (specify):

Needs assist of 1-2 persons

Bedbound (Partial/Complete)

Mobility/Ambulatory device(s) used:

Unsteady Gait

18A

GENITOURINARY STATUS

(Check all that apply:) Nocturia xUrgency/frequencyBurning/pain Hesitancy Hematuria Oliguria/anuriaIncontinence: Urinary Bowel Diapers/other:

Blood-tingedColor: Yellow/straw Amber Brown/gray Other: Clarity: Clear Cloudy Sediment/mucousOdor: Yes No Urinary Catheter: Type Last changed on: Foley inserted (date) with FrenchInflated balloon with mL without difficulty Suprapubic Irrigation solution: Type (specify): Amount mL Frequency ReturnsPatient tolerated procedure well Yes No Urostomy (describe skin around stoma):

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NUTRITIONAL STATUS

GENITALIADischarge/Drainage: Urine/Vag. mucus/FecesLesions/Blisters/Masses/Cysts Inflammation

Surgical alteration

NUTRITION HEALTH SCREEN

Prostate problem: BPH/TURP Date / /

Directions: Circle each area with ''yes'' to assessment, then total score

Self-testicular exam Freq.

to determine additional risk. YESHas an illness or condition that changed the kind and/or amount offood eaten. 2Eats fewer than 2 meals per day. 3Eats few fruits, vegetables or milk products. 2Has 3 or more drinks of beer, liquor or wine almost every day. 2Has tooth or mouth problems that make it hard to eat. 2Does not always have enough money to buy the food needed. 4Eats alone most of the time. 1Takes 3 or more different prescribed or over-the-counter drugs a day. 1Without wanting to, has lost or gained 10 pounds in the last 6 months. 2Not always physically able to shop, cook and/or feed self. 2

TOTAL

Menopause: DateHysterectomy / /Date last PAP Results/ /

Breast self-exam. freq. Discharge: R/LMastectomy: R/L Date / /Other (specify incl. hx)

NO PROBLEM

HEMATOLOGY/ IMMUNEAnemia: Iron deficient/Pernicious 2o Bleed: GI/GU/GYN/Unknown

Ablastic/Hemolytic/PolycythemiasThrombocytopenia Coagulation disordersHemophilia, other

INTERPRETATION

Malignancies (specify):

0-2 Good. As appropriate reassess and/or provide information based on situation.3-5 Moderate risk. Educate, refer, monitor and reevaluate based on patient

Prior RxComplications

situation and organization policy.

Other (specify, immunological problem)

6 or > High risk. Coordinate with physician, dietitian, social service professionalor nurse about how to improve nutritional health. Reassess nutritional status andeducate based on plan of care.

NO PROBLEM

NEUROLOGICALOriented X

NO PROBLEMReprinted with permission by the Nutrition Screening Initiative, a project of the American Academy ofFamily Physicians, the American Dietetic Association and the National Council on the Aging, Inc., andfunded in part by a grant from Ross products Division, Abbott Laboratories Inc.

Insomnia/Change in sleep patternSlurred speech

ELIMINATION STATUS

SyncopeVertigoSensory lossAtaxia

Usual frequencyLast BM / /

NumbnessHx of frequent falls

>3x/day

of 5 www.pnsystem.com 305.818.5940 ADULT NURSING ASSESSMENT (RECERT)

SAFETY MEASURES

Origin:

OnsetLocation

Quality (i.e., burning, dull ache)Intensity level: 0 1 2 3 4 5 6 7 8 9 10Freq./Duration

Aggravating/Relieving Factors:

Pain Management History

SKIN CONDITION/WOUNDS/LESION

Present Pain Management Regimen

Effectiveness

Sutures Staples

Turgor: Good Poor

Other (specify)

NO PROBLEM

Edema: Lymph Hema.Other (specify, incl. pertinent hx)

APPLIANCES/AIDS/SPECIAL EQUIPMENT:Wheelchair

Cane WalkerCrutch(es)

NO PROBLEM

Other (specify):

Denote location of specific skin conditions/wounds by numberingappropriately on illustrations below.

Prosthesis: Hospital bed

Oxygen: HME Co.

Phone:

Fire Alarm Smoke Alarm

Size (cm)Depth

MUSCULOSKELETALFracture (location)Swollen, painful joints (specify)

LocationContractures: JointPoor conditioningAtrophyParesthesiaDecreased ROM

Shuffling/Wide-based gait WeaknessAmputation: BK/AK/UE; R/L (specify)

QuadriplegiaParaplegiaHemiplegiaOther (specify, incl. pertinent hx)


#ICONDITION #2 #3 #4

Safety Measures: CMS485 (POC)Cast PrecautionsChange position slowlyCoumadin/Heparin PrecautionsDo not lift, bend, stoopGood handwashing techniqueOxygen Precaution/Fire preventionPractice Universal Precautions

15

Safe Ambulation

Respiratory PrecautionsDiabetic PrecautionsWound/Decubitus precautionsAdequate lightingPrevent Cardiac OverloadPrevent Falls and Injuries G.I. Precautions

Prev. Infection ComplicationsSeizure PrecautionsSuicide precautionsSupport due functional limitationTeach coping skillsSafe storage/disposal syringes Cardiac Precautions

G.U. Precautions

Safe TransfersSAN PrecautionsCatheter CareProvide Emotional SupportEmergency Plan

Maintain Safe/clear EnvironmentMaintain Good Skin care

Clear pathways

Other:

SG

Correct handwashing technique SGCheck bathroom, floor/stairs for safety hazards

SG

PAIN MANAGEMENTItch Rash Dry Scaling Incision Wounds LesionsDecubitus Fistulas Abrasions LacerationsBruises Ecchymosis Pallor: Jaundice Redness

Stage

Drainage/Amt.

TunnelingOdor

Sur. Tis.Edema

Stoma

None known / NKA AspirinSulfaPollens and mold spores

EggsPenicillin

Insect bitesDairy/Milk products

Other

17

Iodine Dust mitesAnimal dander and urine

ALLERGIES

Lifts Bedside Commode

Patient is prone to FALL: Yes:NoFall risk assessment conducted every_______________Fall prevention program in place, patient instructed SG

Comment:

HOME ENVIRONMENT SAFETYSafety hazards in the home: (check all that apply)

NYFire alarm/smoke detector /Fire extinguishInadequate heating/ cooling/ electricity / lightingHurricane, Disaster Emergency supplies/kits

NYY N

NYFirst aid box/Emergency Equipment or SuppliesNYUnsafe gas/electrical appliances or electrical outletsNYInadequate running water, plumbing problemsNUnsafe storage of supplies/ equipment/ HME

No telephone available and/or unable to use the phonePest problems, Insects/rodentsMedications stored safely, clearly-easy use

NYNYNY

Emergency planning, Exit Plan in place, more than one exit Y NNYEnough Ventilation

Safe Beds/Chairs, clear pathwaysY NAble to follow directions in case of Emergency

NYSlippery Floors, Ashtrays (if a smoker)NYPlan for power failure, emergency lights, flashlights, etc.

Y

NY

NYRelevant medical appliances, if applicable ( wheelchair, O2, Monitors, etc.)NYHurricane Shutter , Disaster Plan

ENTERAL FEEDINGS - ACCESS DEVICE - IVNasogastric Gastrostomy Jejunostomy Feeding type:

Pump: (type/specify) Bolus Continuous

TPNDevice: IV:

N/AFinancial ability to pay for medications/insurance covered: Yes NoComment:

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ACTIVITY PRIOR Level of Function I A D COMMENTS (who assists, assistive device used, etc.)Eating/Kitchen accessTransfer abilitiesDressing/GroomingBathing/ Personal CareToileting/Hygiene abilitiesAmbulation/ROMCommunication (verbal, non-verbal)Preparing/Serving light mealsPreparing full mealsLight housekeepingPersonal laundryHandling moneyUsing telephoneReading,

Managing MedicationsOther (Specify)

ACTIVITIES OF DAILY LIVING (Legend: I-Independent; A-Assist; D-Dependent)

G O A L S

DISCHARGE PLANS

Yes NoDiscussed with patient/client?

NoYesDRUG REGIMEN REVIEW COMPLETED?PATIENT/CLIENT/CAREGIVER RESPONSE

ISUMMARY CHECKLIST SIGNATURES/DATESx / /

PatientlClientlCaregiver (optional if weekly is used) Date

/ /Nurse signature/title Date

PRN order obtainedOrder obtainedNo changeMEDICATION STATUS:Yes NoMEDICATION SCHEDULE/RECORD FILL OUT?

PT OT S T MSWPhysicianCARE COORDINATION:SN Aide Other (specify)

PATIENT/CLIENT NAME - Last, First, Middle Initial Med. Record #

2.3.4.

10

WritingHair care, Skin Care

www.pnsystem.com 305.818.5940 ADULT ASSESSMENT (RECERT)Page 5 of 5

RefusedIndications for Home Health Aide may be continued:

NoYesMD Order obtained:

OTSN MSWOther Services ordered: STPT Comment:

If the patient continue experiment:-ADL/IADL Deficit - Elimination Deficit - Impaired Mobility:

Patient/Family:

N/A (Home Health Aide Services not needed)

SKILLED NURSING INTERVENTION/SERVICE

Instructions/Information Provided (Check all that apply):

Patient Rights and responsibilitiesState hotline/ABUSE numberAdvance directives information

Do not resuscitate (DNR) (if applicable)Service Agreement/ContractOASIS/HIPAA Privacy Notice, Confidentiality

Emergency Plan, classification, instructionsAgency phone numbers, addressClient Information Handbook

Standard precautions /handwashing/ Infection Control

Home safety guidelines

Admission criteria, Information for Home visit, Services, FrequencyDiabetes Control, other disease management information

Other

Medication sheet, instructions

Alzheimer's, Fall prevention, Sensory impairments info

Care Plans

Pain Management info Grievance Procedures

Local Resources Guide Mission, ownership information

Skilled Observation / AssessmentINJECTION ROUTE:_______ SITE: _____ MED. GIVEN: ______________________ DOSE: __________ REACTION: _____________________________

Foley Change/Care Patient Education/teaching Wound Care / Dressing Change Prep. / Admin. Insulin

Standard/Universal Precautions Followed Aseptic Tech. Used. Quality Control of Glucometer Performed Sharps Discarded Inside Sharps Container

Procedure/Tx welltolerated by Pt.

Diabetic Observation / Care

Correct handwashing technique followed SG Management/Evaluation Patient's Care Plan No caregiver/family available/willing to help patient with care, procedures.

SN or ______ - ORDERS - FREQUENCY/DURATION:21AIDE - ORDERS - FREQUENCY/DURATION:

TUB/SHOWER BATH PERSONAL CAREHAIR COMBORAL HYGIENETPR

ASSIST TO DRESS

WASH CLOTHESLIGHT HOUSEKEEPING

ASSIST WITH PERSONAL CARE AND ADL'SPERI CARE

REPORT SIGNIFICANT FINDING TO AGENCY/CASE MANAGER

OTHER:

RETURN TO INDEPENDENT AMBULATION. BE SAFE IN SELF CARE.PATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVERWITHIN HIS/HER CURRENT LIMITATIONS AT HOME.

GOOD/FAIR RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY.

22

PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATIONS AT HOME.OTHER:

WILL DISCHARGE THE PATIENT WITHIN ____ WEEKS, WHEN PATIENT AND/ORCAREGIVER IS/ARE ABLE TO DEMONSTRATE PROPER CARE MANAGEMENT, NO S/S COMPLICATIONS.PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT HOME.OTHER:

REHAB POTENTIAL LEVEL:

60 DAYS SUMMARYIN THE PREVIOUS PERIOD

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Authority to Sign on Behalf of PatientThe undersigned has the authority to sign documents for the following patient:

MR#Patient Name/Nombre del Paciente

The reason for this authorization is as follows:

Patient is unable to sign because:

The reason I am qualified to sign is (check one):

Attach copy of order appointing guardian.1. Guardianship -State exactly how related.Relative2. -

Owner of Health Care Facility - State whether individual, partner,stockholder, director or officer, and state full name of facility.

3.

State with specificity why you are empoweredIf other than above4. -to sign.

El abajo firmante tiene la autoridad para firmar documentos con referencia alpaciente cuyo nombre está escrito arriba.La razón por la cual esta autorización es necesaria es la siguiente:El Paciente no puede firmar porque:

Autorización Para Firmar en Lugar del Paciente

La razón por la cual tengo autoridad para firmar es (marque uno):Agregue la copia de la orden asignando la tutela.Tutela1. -

Especifique exactamente la relación.Familiar2. -3. Dueño de un centro de cuidados médicos - Indique si es individual,

asociado, director, accionista, u oficial, e indique eI nombre completodel centro.

4. Si hay otras razones que no sean las de arriba, indique especificamenteporque usted tiene el poder de firmar.

Date/FechaSignature/Firma

Witness/Testigo Date/Fecha

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Patient Name: _____________________________ MR# ___________________

Staff Change (Discipline: ____________)

Complete the following:

1. The original Employee/contracted _____________________________was changed on (date) _____________.

2. The new assigned Employee (name) _______________________________ was contacted on (date) _____________ and approved this change.

3. The reason for change was: _____________________________________

____________________________________________________________

____________________________________________________________

Office staff (name) ____________________________________________

_____________________________ _____________________Signature of Agency Representative Date

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HOME HEALTH/HOME CAREAIDE WEEKLY VISIT RECORD

EMPLOYEE NAME/TITLE

EMPLOYEE NO.When completing be sure to follow the Aide Assignment Sheet/Care Plan

WEEK OF / SEMANA DEFRI SATDAY- SUN MON TUE WED THUDATE / FECHA / /

THROUGH / A/ /

COMMENTS (All comments must be dated)MON TUE WED THU FRIACTIVITIES SUN

BA

TH

HY

GIE

NE

/GR

OO

MIN

GNU

TRIT

ION

OT

HE

R

EMPLOYEE SIGNATURE(Firma del empleado)/TITLE(Título)/DATE(Fecha):

/ /MR #PATIENT/CLIENT NAME Last First Middle Initial (Nombre del paciente):

SAT

TIME IN / HORA DE ENTRADA:

TIME OUT/ HORA DE SALIDA:

VITA

LS

Tub/Shower/ Bañera/Ducha

R __________ P _________

T _______

Bath: Bed/Sponge-Cama/Sponja - Partial/CompleteAssist Bath Chair/Asistir baño en sillaPersonal Care/Cuidado Personal Assist with Dressing/Asistir vestirse Hair Care/Cuidado del cabello ShampooSkin Care/Cuidado de la piel Foot Care/Cuidado de los pies Check Pressure Areas/Ulceras de presión Nail Care/Cuidado de las uñasOral Care/Cuidado oralClean Dentures/Limpiar dentaduras

Weight-Peso / Pain Rating-Dolor (0 - 10 scale)

PRO

CED

UR

ESA

CT

IVIT

Y

Signature/Firma: Date/Fecha

PT ID PERFORMED VIA NAME, DOB, AND ADDRESS(Verifique la identidad del paciente por nombre,fecha de nacimiento y dirección)Communication with Agency (llamo al supervisor)/Supervisor:

AM AM AM AM AM AM AMPM PM PM PM PM PM PMAMPM

AMPM

AMPM

AMPM

AMPM

AMPM

AMPM

Last Bowel Movement/Ultima vez al baño(necesidades)Other/Otro (specify):

Meal Preparation/Prep. de comida Assist with Feeding/Asistir alimentar

Grocery Shopping/Comprar comida

Exercise Per PT/0T/SLP Care Plan/ Ejercicios por Plan de CuidadoOther/Otro (specify):

ROM Active/Passive (Rango de Mov.Activo/Pasivo ) Arm R/L Leg R/L

Assist with Ambulation - WC/Walker/CaneAyudar con Ambulación, SillaRueda/Andador/BastonAssist with Mobility: ChairBed/ Dangle/Commode/Shower/TubAsistir con mobilidad (silla,cama,cuña,pato,ducha,bañera)

Other/Otro (specify):

Light Housekeeping (Ligera limpieza)- Bedroom(cuardto)/Bath-room(baño)/Kitchen(cocina) - Change Bed Linen(cambiar sabanas)

Equipment Care/Cuidado de equipos

Positioning-Encourage Assist (Cambio de Posiciones) ________ hrs

Limit/Encourage Fluids - Limitar/Exigir Fluidos

Wash Clothes/Lavar ropa

Other/Otro (specify):

Inspect/Reinforce Dressing/Inspeccionar VendasMedication Reminder/Recordar medicinas

Other/Otro (specify):Assist with Elimination/Asistir eliminación Catheter Care/Cuidado de catetes

Record Intake/Output-Registro tomar/salidaOstomy Care/Cuidar ostomia

Shave / Afeitar

BP _________

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Name: LAST FIRST MIDDLE MED.RECORD #:

Photographic Wound Documentation

Date: __________________

Picture Taken by:

________________________

Date: __________________

Picture Taken by:

________________________

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SOCIAL SERVICEDATA BASELINE

GENERAL INFORMATIONDOB: Sex:Patient Name

HIC # Age:Patients MR#Diagnosis

Prior Agency AdmissionsNo If yes, but not seen explain:YesPrior Referral to Social Services:

Reason for Present Referral to Social Service

PATIENT PROFILEPatient's Understanding of Reason for Referral

Pers General AppearancePlaceTimeOrientation:Age came to U.S.Place of BirthGoodMotivation: Poor GuardedEmotional Tone

Capacity to Cope with PresentPotential for Change-FAMILY PROFILE / SOCIAL HISTORY

# of Marriages # of yearsDWMMarital Status SChildren:Address:Significant Cult MoresCommunication bet FamilyPatient and Family KnowledgeHousehold Members Health

ImportanceReligionLanguageConditionLiving Arrangement

S/0 involved in Patients CareMonthly IncomeSource of incomeUnmet NeedsInsurance

PERSON TO BE CONTACTEDAddressNameRelationPhone

AGENCIES NEEDED FOR PATIENT AND/OR FAMILYPh WorkerAgencyPh WorkerAgencyPh WorkerAgency

DateSignature

Comment::

PT ID PERFORMED VIA NAME, DOB, AND ADDRESS

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SOCIAL SERVICE NARRATIVE

MR#PATIENT: HIC #

PATIENT:

FAMILY:

DIAGNOSTIC IMPRESSIONS OF SOCIAL WORKER:

TREATMENT GOAL:INCLUDE COMMUNITY AGENCIES TO BE UTILIZED

DATE:SIGNATURE:

I


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MEDICAL SOCIAL SERVICESCARE PLAN

/ /SOC DATEREASON FOR VISIT/PROBLEM

ME

DIC

AL

SO

CIA

L S

ER

VIC

ES

MEDICAL SOCIAL SERVICES TREATMENT PLANSHORT TERM OUTCOMES Time FramePATIENT/CLIENT DESIRED OUTCOMES LONG TERM OUTCOMES Time Frame

PLAN OF CAREAssessment of social and emotional

factors (E1)Counseling for long-range planning

and decision making (E2)

Services to family member(s)/caregiver(s)Arrange transportation for medicalappointmentsEmotional support to patient/client/familyFinancial resource information Referral to support group(s)/

community resource(s) (specify)Community resource planning (E3) Arrangement of meal servicesShort term therapy (E4) Initiate abuse reporting mechanismIdentify eligibility for services/ benefitsInitiate counseling

Initiate referral to personal emergencyresponse system

Nursing home placement assistance Teach self-management skills Other:Alternate living arrangements Crisis intervention

COMMENTS/ADDITIONAL INFORMATION

PATIENT/CLIENT/CAREGIVER RESPONSE TO PLAN OF CARE

SUMMARY/ /Yes No APPROXIMATE NEXT VISIT DATEGOALS ACHIEVED?

PLAN FOR NEXT VISITSpecify

Yes No DISCHARGE PLAN DISCUSSED WITH:REFERRALS COMPLETED? Patient/Client/ FamilyCare Manager Physician OtherSpecify

DISCHARGE INSTRUCTIONS GIVEN TO PATIENT/CLIENT/NoFAMILY? Yes, specify

/ /CARE COORDINATION: Care Manager, date/ /Physician, date Other (specify)

SIGNATURES/DATES

x / /(signature/title)Medical Social Worker Date

ID#PATIENT/CLIENT NAME - Last, First, Middle Initial

MEDICAL SOCIAL SERVICES CARE PLAN

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OCCUPATIONAL THERAPY CARE PLANDiagnosis/ Reason for OT:Frequency and Duration:

INTERVENTIONS Locator #21Evaluation Body image trainingFine motor coordination

Neuro-developmental trainingSensory treatment

Establish/ upgrade home exercise program Copy given to patient

Teach safe/effective use of adaptive/assistdevice (specify)

Muscle re-educationCopy attached to chart Orthotics/SplintingPatient/Family education Prosthetic training, Adaptive equipment, fabrication Teach fall safety

Pain Management Therapeutic exercise to _____________ to increase strengthIndependent living/ADL training Teach alternative bathing skills

Retraining of cognitive, feeding, and perceptual skillsNote: Each modality specify frequency, duration, amount:

SHORT TERM GOALS Locator #22HEP will be established and initiated. Patient will be able to finalize and demonstrate to follow up HEP.Pain level will decreased from ___/10 to ___/10 within weeks.

Patient will be able to stand in kitchen to prepare meal for _____ min within

Patient will be able to reach _________________ on ________________ withinweeks.

Patient will be able to lift _____ # pounds from ___________ to ___________ within

Patient will be able to wash ____________________________________ within

weeks.

Patient will be able to reach a Cup from _________ and taked to _________ within

weeks.

Patient will be able to integrate orthotic/prosthetic ____________ to ____________within _____weeks.

Equipment needed:YesPatient/Caregiver aware and agreeable to POC: No (explain):

GOALS: OCCUPATIONAL THERAPY Locator #22PoorREHAB POTENTIAL:

DISCHARGE PLAN:ExcellentFair Good

When goals met Other (specify)

Plan developed by: DateSignature/title

Physician signature: DatePlease sign and return promptly

Original - Physician Copy - Clinical Record (until signed original returned)PATIENT NAME - Last, First, Middle Initial ID#

ADDITIONAL SPECIFIC OCCUPATIONAL THERAPY GOALS Locator #22Note: Each modality specify location, frequency, duration, and amount.

Patient Expectation SHORT TERM LONG TERMTime Frame Time Frame

coordination, sensation and proprioceptionOther:

weeks.

ONSET:

Therapist Name

LONG TERM GOALS

weeks.

Pain level will decreased from ___/10 to ___/10 within _____ weeks.

Patient will be able to stand in kitchen to prepare meal for ___ min within ____ weeks.

Patient will be able to reach ___________ on ___________ within

Patient will be able to lift ____ # pounds from __________ to __________ within

Patient will be able to wash __________________________________ within

Patient will be able to reach a Cup from ___________ and taked to ___________ within

Patient will be able to use orthotic/prosthetic _____________ with/without assistanceweeks.whitin

Perceptual motor training

DISCHARGE PLANS DISCUSSED WITH: Patient/FamilyPhysician Other (specify)Care Manager

PT SN STPhysicianCARE COORDINATION:Other (specify)MSW Aide

APPROXIMATE NEXT VISIT DATE:PLAN FOR NEXT VISIT

SAFETY ISSUES/INSTRUCTION/EDUCATION: COMMENTS/ADDITIONAL INFORMATION:OTA

weeks.

weeks.

weeks.

weeks.

Patient will be able to don/doff ______________ with assistance of ______________within _____weeks.

Patient will be able to don/doff ____________________________ independentlywithin _____weeks.

INITIALUPDATED

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OCCUPATIONAL THERAPYREVISIT NOTE

TYPE OF VISIT:HOMEBOUND REASON: Needs assistance for all activities Residual weaknessRevisitRequires assistance to ambulate Confusion, unable to go out of home aloneRevisit and Supervisory VisitSevere SOB, SOB upon exertionUnable to safely leave home unassistedOther (specify)Medical restrictionsDependent upon adaptive device(s)

/ /SOC DATEOther (specify)TREATMENT DIAGNOSIS/PROBLEM AND EXPECTED OUTCOMES:

SUPERVISORY VISIT (Complete if applicable)Reviewed/Revised with patient involvement.CARE PLAN:Aide PresentOT Assistant Not presentIf revised, specify

SUPERVISORY VISIT Scheduled UnscheduledOBSERVATION OFOutcome/Instruction achieved (describe)

TEACHING/TRAINING OFPRN order obtained / /APPROXIMATE NEXT VISIT DATE:PATIENT/FAMILY FEEDBACK ON SERVICES/CAREPLAN FOR NEXT VISIT(specify)

/ /NEXT SCHEDULED SUPERVISORY VISITDISCHARGE PLANS DISCUSSED WITH: Patient/FamilyCARE PLAN UPDATED? No Yes (specify)Physician Other (specify)Care Manager

BILLABLE SUPPLIES RECORDED? N/A Yes (specify)

If OT assistant/aide not present, specify date he/she wasPT SN STPhysicianCARE COORDINATION:/ /contacted regarding updated care plan:Other (specify)MSW

SIGNATURES/DATES

x Complete TIME OUT prior to signing below./ / / /Date DatePatient/Caregiver (if applicable) Therapist (signature/title)

PART 1 - Clinical Record PART 2 - TherapistID#PATIENT NAME - Last, First, Middle Initial

OCCUPATIONAL THERAPY REVISIT NOTE

Time In: ________ Time Out: ________

VITAL SIGNS: Temperature: Pulse: Irregular Respirations: Regular IrregularRegularStanding SittingLeftBlood Pressure: Right Lying/ /

Location(s)Pain: None Same WorseImproved OriginIntensity 0 1 2 3 4 5 6 7 8 9 1 0 Relief measuresDuration Other:

Neuro-developmental training Therapeutic exercise to right/left handto increase strength, coordination,sensation and proprioception

EvaluationEstablish home exercise program Sensory treatment

Copy given to patient Orthotics/SplintingTeach fall safetyPain managementOther:

Copy attached to chart Adaptive equipment (fabricationand training)Patient/Family education

Independent living/ADL trainingMuscle re-education

Teach alternative bathing skills(unable to use tub/shower safely)

Perceptual motor trainingFine motor coordination

Retraining of cognitive, feedingand perceptual skills

OBSERVATIONS, INSTRUCTIONS AND MEASURABLE OUTCOMES:

EVALUATION AND PATIENT/CAREGIVER RESPONSE:

OCCUPATIONAL THERAPY INTERVENTIONS/INSTRUCTIONS (Mark all applicable with an ''X''.)

Modality used LocationFrequencyDurationIntensityOther



Aide


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OCCUPATIONAL THERAPY

/ /DATE OF SERVICEOUTTIME INOBJECTIVE DATA TESTS AND SCALES PRINTED ON OTHER PAGE.

TYPE OF EVALUATIONNeeds assistance for all activitiesHOMEBOUND REASON: Residual weaknessRequires assistance to ambulate Confusion, unable to go out of home alone FinalInterimInitial

Severe SOB, SOB upon exertionUnable to safely leave home unassisted / /SOC DATEDependent upon adaptive device(s) Medical restrictions(if Initial Evaluation, complete OccupationalTherapy Care Plan)Other (specify)

ORDERS FOR EVALUATION ONLY? No If No, orders areYes

PERTINENT BACKGROUND INFORMATION

TREATMENT DIAGNOSIS/PROBLEM

/ONSETMEDICAL PRECAUTIONS

ACTUAL LEVEL OF FUNCTION (ADL / IADL)

LIVING SITUATION/SUPPORT SYSTEM

ENVIRONMENTAL BARRIERS

PERTINENT MEDICAL/SOCIAL HISTORY AND/OR PREVIOUS THERAPY PROVIDED

SENSORY/ PERCEPTUAL MOTOR SKILLSLight/Firm Touch VISUAL TRACKING:ProprioceptionSharp/Dull

Right I Left I Right I LeftRight I LeftArea I R/L DISCRIMINATION:MOTOR PLANNING PRAXIS:

NoYesDo sensory/perceptual impairments affect safety?If Yes, recommendations:

COMMENTS:

Area I MIN MOD S U ABILITY TO EXPRESS NEEDSMEMORY Short term ATTENTION SPAN

Long term PlaceORIENTED: Person Reason for TherapyTimeSAFETY AWARENESS PSYCHOSOCIAL WELL-BEING JUDGMENT INITIATION OF ACTIVITYVisual Comprehension Evaluate FurtherCOPING SKILLS

COGNITIVE STATUS/COMPREHENSION

SELF-CONTROLAuditory Comprehension

FINE MOTOR COORDINATION (R) GROSS MOTOR COORDINATION (R)FINE MOTOR COORDINATION (L) GROSS MOTOR COORDINATION (L)

ORTHOSIS:PRIOR TO INJURY: Right Handed Needed (Specify):Left Handed UsedMUSCLE STRENGTH/ FUNCTIONAL ROM EVALUATION (Enter Appropriate Response)

ROM ROM TYPESTRENGTH TONICITYRight I Left I Right I Left I P I AA I A I Hyper I Hypo OTHER DESCRIPTIONSPROBLEM AREA

COMMENTS:

TherapistPART 1 Clinical Record PART 2

OCCUPATIONAL THERAPY EVALUATIONContinued

/

KEY: I - Intact, MIN - Minimally Impaired, MOD - Moderately Impaired, S- Severely Impaired, U- Untested/Unable to Test

Area I MIN MOD S U I MIN MOD S U MOTOR COMPONENTS (Enter Appropriate Response)

PATIENT/CLIENT NAME: Last, First, Middle Initial ID #:

PRIOR LEVEL OF FUNCTION (ADL / IADL)

EVALUATION RE-EVALUATION

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BED MOBILITY

BED/WHEELCHAIR TRANSFER

TOILET TRANSFER

DYNAMIC SITTING BALANCE

STATIC SITTING BALANCE

STATIC STANDING BALANCE

TUB/SHOWER TRANSFER DYNAMIC STANDING BALANCE

FEEDING

SWALLOWING

FOOD TO MOUTH

ORAL HYGIENE

TOILETING

BATHING

UE DRESSING

LE DRESSING

GROOMING MANIPULATION OF FASTENERS

USE OF TELEPHONE

MONEY MANAGEMENT

MEDICATION MANAGEMENT

LIGHT HOUSEKEEPING

LIGHT MEAL PREPARATION

CLOTHING CARE

PATIENT GOALS:

OBJECTIVE DATA TESTS AND SCALES

DESCRIPTIONGRADEDESCRIPTIONGRADENormal functional strength - against gravity - full resistance5

43

100% active functional motion.75% active functional motion.50% active functional motion.25% active functional motion.

5Good strength - against gravity with some resistance.

4Fair strength - against gravity - no resistance - safety compromise.Poor strength - unable to move against gravity.Trace strength - slight muscle contraction - no motion.

muscle contraction.

32

2.1Less than 25%.1

0

ACTION/ MOVEMENTAREADESCRIPTIONGRADEShoulder 158Flex

170Abd.70Int. rot.

55Extend50Add.90Ext. rot.

ElbowForearmWristFingers

145Flex85Sup.73Flex90Flex all

0Ext.70Pron.70Ext.0Ext.

5 Physically able and does task independently.4 Verbal cue (VC) only needed.

Stand-by assist (SBA) - 100% patient/client effort.Minimum assist (Min A) - 75% patient/client effort.Maximum assist (Max A) - 25% - 50% patient/client effort.Totally dependent - total

3210

50%AbductionThumb35Flex 35Ext.45Rotation

GRADE DESCRIPTION Cervical5 SpineIndependent4 Verbal cue (VC) only needed.

Stand-by assist (SBA) - 100% patient/client effort.Minimum assist (Min A) - 75% patient/client effort.Maximum assist (Max A) - 25% patient/client effort.Totally dependent for support.

3210

OCCUPATIONAL THERAPY (Cont'd.)

TASK SCORE COMMENTS TASK SCORE COMMENTS

FUNCTIONAL MOBILITY/BALANCE EVALUATION

SELF CARE SKILLS

INSTRUMENTAL ADL'S

MANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH FUNCTIONAL RANGE OF MOTION (ROM) SCALE

FUNCTIONAL INDEPENDENCE, SELF-CARE SKILLS AND INSTRUMENTAL ADL SCALE

o

o

AVERAGE RANGES OF JOINT MOTION (ROM)

o

oo

o

o

o

o

o

o

o

o

o

o

o

oBALANCE SCALE (sitting-standing)

MED. RECORD #:PATIENT'S NAME:

THERAPIST'S/ /SIGNATURE/TITLE DATE PHYSICIAN'SSIGNATURE / /DATE

* If no changes made to Initial Plan of care, MD signature no required.


CHANGE

NOT CHANGE

FOR RE-EVALUATION USE ONLY:IF A PREVIOUS PLAN OF CARE WAS ESTABLISHED, THEN IT WILL:

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PHYSICAL THERAPY CARE PLAN

INTERVENTIONS Locator #21Evaluation Teach hip safety precautionsBalance training /activities

Pulmonary Physical TherapyUltrasound to _____ at _____ x _____ min

Establish/ upgrade home exercise program Copy given to patient

Teach safe/effective use of adaptive/assistdevice (specify)

Teach safe stair climbing skillsCopy attached to chart Electrotherapy to _____ for _____ minPatient/Family education Prosthetic training Teach fall safetyTherapeutic exercise TENS to _____ for _____ min Pulse oximetry PRNTransfer training with/without assistance Functional mobility training Heat/Cold to _____ for _____ minGait training with/without assistance Teach bed mobility skills

Note: Each modality specify frequency, duration, amount and specify location:

SHORT TERM GOALS Locator #22

Gait will increase tinetti gait score to _____ / 12 within ______ weeks.

Equipment needed:YesPatient/Caregiver aware and agreeable to POC: No (explain):

PoorREHAB POTENTIAL: ExcellentFair Good

Plan developed by: DateTherapist Name/Signature/title

Physician signature: DatePlease sign and return promptly

Original - Physician Copy - Clinical Record (until signed original returned)PATIENT NAME - Last, First, Middle Initial ID#

ADDITIONAL SPECIFIC THERAPY GOALS Locator #22Note: Each modality specify location, frequency, duration, and amount.

Patient Expectation SHORT TERM LONG TERMTime Frame Time Frame

Therapeutic massage to _____ x _____ min

GENERAL

Will improve gait requiring ____ to _____ from _____ to ______ within ____ weeks.BED MOBILITY

Pt. will be able to turn side (facing up) to lateral (left/right) within ____ weeks.Pt. will be able to butt scoot within _____ weeks.Pt. will be able to sit up with/without assistance _______ within ______ weeks.

BALANCEWill increase tinetti balance score to _____/16 within _____ weeks.Pt. will be able to reach steady static/dynamic sitting/standing balance with/without assistance ______ within ______ weeks

TRANSFERPt. will be able to transfer from _________ to _________ with/without assistance _____ within ____ weeks.

MUSCLE STRENGTHPt. will be able to hold weigh _______ lb within ________ weeks.

PAINPain will decrease from ____/10 to ____ /10 within _______ weeks.

Pt. will be able to oppose flexion or extension force over _____ within ______ weeks.

ROMPt. will increase ROM of ________ by ______ degrees flexion/extension within _____ weeks.

SAFETYPt. will be able to use _____ with/without assistance to _____ feet within ______ weeks.Pt. will be able to propel wheel chair _____ feet within _______ weeks.HEP will be established and initiated.

STAIR/UNEVEN SURFACEPt. will be able to climb stair/uneven surface with/without assistance _____ steps #_______ within ________ weeks.

Gait will increase tinetti gait score to _____ / 12 within ______ weeks.GENERAL

Will improve gait requiring ____ to _____ from _____ to ______ within ____ weeks.BED MOBILITY

Pt. will be able to turn side (facing up) to lateral (left/right) within ____ weeks.Pt. will be able to lie back down within _____ weeks.Pt. will be able to sit up independently _______ within ______ weeks.

BALANCEWill increase tinetti balance score to _____/16 within _____ weeks.Pt. will be able to reach steady static/dynamic sitting/standing balance with/without assistance ______ within ______ weeks

TRANSFERPt. will be able to transfer from _________ to _________ with/without assistance _____ within ____ weeks.

MUSCLE STRENGTHPt. will be able to hold weigh _______ lb within ________ weeks.

PAINPain will decrease from ____/10 to ____ /10 within _______ weeks.

Pt. will be able to oppose flexion or extension force over _____ within ______ weeks.

ROMPt. will increase ROM of ________ by ______ degrees flexion/extension within _____ weeks.

SAFETYPt. will be able to use _____ independently to _____ feet within ______ weeks.Pt. will be able to self propel wheel chair _____ feet within _______ weeks.Pt will be able to finalize and demonstrated to follow up HEP.

STAIR/UNEVEN SURFACEPt. will be able to climb stair/uneven surface with/without assistance _____ steps #_______ within ________ weeks.

Pt. will be able to self reposition within ______ weeks.

LONG TERM GOALS

INITIALUPDATED

DISCHARGE PLANS DISCUSSED WITH: Patient/FamilyPhysician Other (specify)Care Manager

OT SN STPhysicianCARE COORDINATION:Other (specify)MSW Aide PTA

APPROXIMATE NEXT VISIT DATE:PLAN FOR NEXT VISIT

Diagnosis/ Reason for OT:Frequency and Duration:

ONSET:

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PHYSICAL THERAPYREVISIT NOTE

VITAL SIGNS: Temperature: Pulse: Irregular Respirations: Regular IrregularRegularStanding Sitting LeftBlood Pressure: Right Lying/ /

Location(s)Pain: None Same WorseImproved OriginIntensity 0- 1 0 Relief measuresDuration Other

TYPE OF VISIT:HOMEBOUND REASON: Needs assistance for all activities Residual weaknessRevisitRequires assistance to ambulate Confusion, unable to go out of home aloneRevisit and Supervisory VisitSevere SOB, SOB upon exertionUnable to safely leave home unassistedOther (specify)Medical restrictionsDependent upon adaptive device(s)

Other (specify)

TREATMENT D IAGNOSIS/PROBLEM AND EXPECTED OUTCOMES:

Evaluation (B1)PHYSICAL THERAPY INTERVENTION/INSTRUCTIONS (Mark all applicable with an ''X''.)

Copy given to patientCopy attached to chart

SAFETY ISSUESROM:Obstructed pathwaysHome environmentStairsUnsteady gaitVerbal cues requiredEquipment in poor conditionBathroomCommodeOthers:

SUPERVISORY VISIT (Complete if applicable)Reviewed/Revised with patient involvement.CARE PLAN:Aide / PresentPT Assistant Not presentIf revised, specify

SUPERVISORY VISIT Scheduled UnscheduledOBSERVATION OFNeed for referral (specify)

TEACHING/TRAINING OF

PATIENT/FAMILY FEEDBACK ON SERVICES/CARE(specify)

/ /NEXT SCHEDULED SUPERVISORY VISITDISCHARGE PLANS DISCUSSED WITH: Patient/FamilyCARE PLAN UPDATED? No Yes (specify)Physician Other (specify)Care Manager

BILLABLE SUPPLIES RECORDED? N/A Yes (specify)

If PT assistant/aide not present, specify date he/she wasPT/PTA OT SLPPhysicianCARE COORDINATION:/ /contacted regarding updated care plan:HHA Other (specify)MSW SN

SIGNATURES/DATES

x Complete TIME OUT prior to signing below./ / / /Date DatePatient/Caregiver (if applicable) Therapist (signature/title)

PART 1 - Clinical Record PART 2 - TherapistID#PATIENT NAME - Last, First, Middle Initial

STRENGTH:BALANCE:AMBULATION:ASSESSMENT:

PLAN FOR NEXT VISIT:

Establish/Upgrade home exercise program

Patient/Family educationTherapeutic exercise (B2)Transfer training (B3)Gait training (B5)

Balance training/activitiesTENSUltrasound (B7)Electrotherapy (B8)Prosthetic training (B9)Preprosthetic trainingFabrication of orthotic device (B10)Muscle re-education (B11)

Management and evaluation of care plan (B12)Pulmonary Physical Therapy (B6)Cardiopulmonary PTPain ManagementCPM (specify)Functional mobility trainingTeach bed mobility skillsTeach hip safety precautions

Teach safe stair climbing skillsTeach safe/effective use of adaptive/assistdevice (specify)Other:

TIME IN OUT

O2 saturation ____ % (when ordered)

DATE OF SERVICE:





SOC DATE:

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PHYSICAL THERAPY

/ /DATE OF SERVICETIME IN OUTOBJECTIVE DATA TESTS AND SCALES PRINTED ON OTHER PAGE.

HOMEBOUND REASON: TYPE OF EVALUATIONNeeds assistance for all activities Residual weaknessFinalInitialRequires assistance to ambulate Confusion, unable to go out of home alone Interim

Severe SOB, SOB upon exertionUnable to safely leave home unassisted / /SOC DATEMedical restrictionsDependent upon adaptive device(s)(if Initial Evaluation, complete Physical Therapy

Other (specify) Care Plan)

Chest PTTransfer TrainingTherapeutic Exercise Gait TrainingHome Program InstructionEvaluationPT ORDERS:Other:Prosthetic TrainingElectrotherapy Muscle Re-educationUltrasound

PERTINENT BACKGROUND INFORMATION

TREATMENT DIAGNOSIS/ PROBLEMONSET

MEDICAL HISTORY PRIOR/CURRENT LEVEL OF FUNCTIONIFracturesHypertension

Cardiac CancerDiabetes Infection

ImmunosuppressedRespiratory

Prior level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)

Osteoporosis Open woundOther (specify)

LIVING SITUATION

Current level of function (ADL/IADL) Specify: (ADL/IADL On Problematic Areas)

AbleCapable Willing caregiver availableLimited caregiver support (ability/willingness)No caregiver available

HOME SAFETY BARRIERS: PERTINENT MEDICAL/SOCIAL HISTORY AND/ORPREVIOUS THERAPY RECEIVED AND OUTCOMESClutter Throw rugs

Needs grab bars Needs railingsSteps (number/condition)Other (specify)

BEHAVIOR/MENTAL STATUSAlert Oriented Cooperative

Impaired JudgementConf used Memory deficitsOther (specify)

PAININTENSITY: 0 1 2 3 4 5 6 7 8 9 10LOCATION:AGGRAVATING /RELIEVING FACTORS:

VITAL SIGNS/CURRENT STATUSBP: T.P.R.: Edema: Sensation:

Muscle Tone: Posture:Skin Condition:Communication- Vision: Hearing:Endurance: Orthotic/ Prosthetic Devices:

PART 1 PART 2 TherapistClinical Record- -ID#PATIENT/CLIENT NAME - Last First, Middle Initial

PHYSICAL THERAPY EVALUATION

/ /MEDICAL PRECAUTIONS:

Assistive Device:Needs:

Has:

PAIN TYPE (dull, aching, etc):PATTERN (Irradiation):


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PHYSICAL THERAPY (Cont'd.)

AREA ASSISTIVE DEVICES/COMMENTSTASKACTION ASSISTSCORELeftRoll/Turn

Sit/Supine

Shoulder Flex/Extend

Abd./Add.

Int. rot./Ext. rot. Scoot/Bridge

Sit/Stand

Bed/Wheelchair

Toilet

Floor

Auto

Static Sitting

Dynamic Sitting

Static Standing

Dynamic Standing

Propulsion

Pressure Reliefs

Foot Rests

Locks

TRAN

SFER

S

Elbow Flex/Extend

Forearm Sup./Pron.

Wrist Flex/Extend

Fingers Flex/Extend

Flex/Extend

Abd./Add.

Int. rot./Ext. rot.

Hip

BALA

NC

E

UP

PE

R E

XT

RE

MIT

IES

Knee Flex/Extend

Ankle Plant/Dors

Foot Inver/EverW

/C S

KIL

LS

OBJECTIVE DATA TESTS AND SCALESFUNCTIONAL RANGE OF MOTION (ROM) SCALEMANUAL MUSCLE TEST (MMT) MUSCLE STRENGTH

GRADE DESCRIPTIONDESCRIPTIONGRADENormal functional strength - against gravity - full resistance.5

43210

106% active functional motion.75% active functional motion.50% active functional motion.25% active functional motion.Less than 25%.

54321

Good strength - against gravity with some resistance.Fair strength - against gravity - no resistance - safety compromise.Poor strength - unable to move against gravity.Trace strength - slight muscle contraction - no motion.Zero - no active muscle contraction.

ACTION/MOVEMENTAREAGRADE DESCRIPTIONShoulder 158Flex

170Abd.70Int. rot.

55Extend50Add.90Ext. rot.

ElbowForearmWristFingers

145Flex85Sup.73Flex90Flex all

0Ext.70Pron.70Ext.0Ext.

Hip 901-115Flex45Abd.45Int. rot.

25Ext.30Add.45Ext. rot.

KneeAnkleFoot

135Flex50Plant.30Inv.

10Ext.20Dors.20Ever.

Physically able and does task independently.543210

Verbal cue (VC) only needed.Stand-by assist (SBA)-100% patient/client effort.Minimum assist (Min A)-75% patient/client effort.Maximum assist (Max A)-25% - 50% patient/client effort.Totally dependent-total care/support

BALANCE SCALE (sitting - standing)DESCRIPTIONGRADE

Independent543210

Verbal cue (VC) only needed.Stand-by assist (SBA)-100% patient/client effort.Minimum assist (Min A)-75% patient/client effort.Maximum assist (Max A)-25% patient/client effort.Totally dependent for support.

GAIT

SBAASSISTANCE: Independent UnableMax. assistMod.assistMin. assistSURFACES: DISTANCE:Level Uneven Stairs (number/condition)

PWB NWBTDWBWBATFWBWEIGHT BEARING STATUS:Hemi-walker

WalkerASSISTIVE DEVICE(S):

Wheeled walkerCane CrutchesQuad caneOther (specify)

QUALITY/DEVIATIONS:PATIENT INFORMATION

MED. RECORD #:PATIENT'S NAME:

THERAPIST'S/ /SIGNATURE/TITLE DATE

MUSCLE STRENGTH/FUNCTIONAL ROM EVAL FUNCTIONAL INDEPENDENCE/BALANCE EVAL

LOW

ER

EX

TR

EM

ITIE

S

RightROMSTRENGTH

Right Left

BED

MO

BILI

TY

FUNCTIONAL INDEPENDENCE SCALE (bed mobility, transfers, W/C skills) NORMATIVE DATA FOR JOINT MOTION (ROM)o

oo

oo

o

o

o

o

o

o

o

o

oo

o

o

oo

o

o

o

o

oo

o

PHYSICIAN'SSIGNATURE / /DATE* If no changes made to Initial Plan of care, MD signature no required.


CHANGE

NOT CHANGE

FOR RE-EVALUATION USE ONLY:IF A PREVIOUS PLAN OF CARE WAS ESTABLISHED, THEN IT WILL:

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NURSING DISCHARGE SUMMARY / NOTE

DR.PATIENT

ADDRESSMED REC # ADM DATE DISCH DATE

CITY, ZIP TELDIAGNOSIS (Primary)

REASON FOR DISCHARGE:SERVICES RENDERED: Frequency on ADM to Discharge PARTIAL - STILL RECEIVING SERVICES OF:

H H ASN P T S T OT HHACOMPLETEMSW DIETICIAN

CONDITION ON DISCHARGE: DISPOSITION OF THE PATIENT:IMPROVEDSTABLE ABLE TO CARE FOR SELF FAMILY TO ASSIST

UNSTABLE DECEASED INSTITUTIONALIZED HOMEMAKER TO ASSIST DECEASED

LAST M.D. VISIT: RN CONTACTED PHYSICIAN ON DATE: AND DISCHARGE IS APPROVED.LAB REPORTS SUMMARIZE:

CHANGE ORDERS / NEW DIAGNOSIS:N OYES

SUMMATION OF SERVICES RENDERED AND GOALS ACHIEVEDVERBALIZES KNOWLEDGE OF MEDICATIONS, SIDE EFFECTS, PRECAUTIONS, PRESENTING SYMPTOMS ABSENT AND/OR CONTROLLED BY APPROPRIATEDIET. FLUIDS, DISEASE PROCESS, TREATMENT PROGRAM.S/S NECESSITATING MEDICAL ATTENTION.

INTERVENTION.INDEPENDENCE IN SELF CARE WITHIN DISEASE LIMITATIONS.

RETURN TO PREVIOUS LIFESTYLE WITH MODIFICATIONS WITHIN DISEASE MAXIMUM POTENTIAL OF SKILLED SERVICES ATTAINED WITHIN HOMELIMITATIONS. SETTING.HOME FREE OF HAZARDS USING PROPER SAFETY MEASURES.

SKILLED OBSERVATION / ASSESSMENT ON DISCHARGEDISCHARGED V/S

MENTAL STATUS: PULMONARY:VITAL SIGNS RANGE:CLEARALERT RONCHILUNGS:DISORIENTED CARDIAC/CIRCULATORY:TOBP

IBS RALES WHEEZINGFORGETFUL CONFUSED FREQUENCY OF CHEST PAINAP TOREQUIRED02ANXIOUS FREE OF CHEST PAINTOR R

NOT REQUIREDTOTEMP CONTROLLED ON MEDICATIONENDOCRINE:

EDEMA: TRACENONEDIABETESINCONTINENTGU/Gl: MODE RATE PITTING DIET CONTROLLEDNORMALVOIDING NON-PITTINGDERMA: ORAL HYPOGLYCEMICFOLEY CATHETER FAIRTURGOR GOOD NUTRITION: INSULIN DEPENDENTREGULATEDBOWELS POOR DIET EENT:NOT REGULATED

WOUND/DECUBITUS: HEALED HEARINGTUBE FEEDING TPNOSTOMYPOORGOODNOT HEALED-PT/FAMILY APPETITE:CATHARTIC REQUIRED

VISIONDEMONSTRATES PROPER WOUND GOOD FAIR POORGOOD POORCARE

PATIENT / FAMILY INSTRUCTED IN:POST CATARACT CAREINJECTION ADMINISTRATION ACTIVITY RESTRICTIONS

CARE OF TERMINALLY ILLDISEASE PROCESS ADMINISTRATION OF TUBE FEEDINGSDIABETIC MANAGEMENTS/S OF COMPLICATIONS ADMINISTRATION OF INHALATION RXDIET/FLUID INTAKEACTION/SIDE EFFECTS OF MEDS IV THERAPYOSTOMY/CONDUIT CAREFOLEY CARE FIT. INDWELLING CATHETER CARE/PRECAUT.SAFETY FACTORSWOUND/DECUBITUS CARE S/S COMPLICATIONS/INFECTION

POOR REPETITIVE TEACHING REQUIREDFAIRGOODPT/FAMILY RESPONSE AND ADHERENCE TO TEACHINGS:NO .... IF NO, EXPLAINYESNURSING GOALS MET:

NO ... IF NO, EXPLAINYESPATIENT/FAMILY GOALS MET:

ADDITIONAL COMMENTS AND INSTRUCTIONS:

DATERN SIGNATURE


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SKILLED NURSING VISIT NOTE

DATE OF VISIT

AM/PM OUTTIME IN AM/PMSN & Super.SNTYPE OF VISIT:

Super. Only Other

VITALST BSWtResp. IrregularReg.Pulse: A R

IrregularReg.

PATIENT NAME - Last, First, Middle Initial ID#

HOMEBOUND REASON: Needs assistance for all activities

Residual weakness

Requires assistance / device to ambulate

Contusion, unable to go out of home alone Unable to safely leave home unassisted


Severe SOB, SOB upon exertion


Other (specify)

MEDICAIDMARK ALL APPLICABLE WITH AN X. CIRCLE APPROPRIATE ITEM MEDICARE MX OTHER

CARDIOVASCULARFluid Retention

B/P SITTING STANDINGGENITOURINARY MUSCULOSKELETAL LYINGRIGHTBurning Dysuria Balance Unsteady gait Endurance

Distension Retention LEFTChest Pain Weakness Ambulates with AssistanceNeck Vein Distension Limited Movement RomFrequency Urgency Hesitancy

Hematuria Chair Bound Bed BoundBladder Incontinence Contracture Paralysis

Edema (specify):RUE LUE RLE LLE

No DeficitNEUROSENSORY

Syncope

Ascites Catheter IleoconduitPeripheral Pulses Suprapubic CatheterArrhythmia Foley Catheter

HeadacheOther: Fr. cc.SizeNo deficit Last Changed:

RESPIRATORY Irrigation cc / nsaRales Ronchi Wheeze Urine

Grasp UnequalEqualRight:Left:

MovementRUE LUE

LLERLEPupil Reaction

Right Left

R. Lung L. Lung cc /Output hr.Cough Sputum ColorDyspnea SOB Consistency

Orthopnea OdorVIA:02. LPM: Pain Discharge

No deficit Cath. Leakage Dislodge Hand TremorsDIGESTIVE Other Poor Hand-Eye coordination

Poor Manual DexterityBowel Sound:Nausea Vomiting Speech impairmentAnorexia NPO Hearing Impairment

Epigastric Distress Visual Impairment BlindnessDifficulty Swallowing Tactile SensationAbdominal Distention

Colostomy IleostomyNo deficit

EMOTIONAL STATUSOriented PPTBowel Incontinence

Constipation Impaction Diarrhea Chills Forgetful ConfusedDiet: Disoriented PPTFluid Intake: Lethargic Semi LethargicEnteral Feeding Route: ComatoseType: Restless Agitated

Anxious DepressedOther

Skilled Observation / AssessmentFoley Change Foley irrigationWound Care Dressing Change

Venipuncture/Lab:

Prep. / Admin. Insulin:

IM Injection:Diabetic Observation / CareLBM: No Deficit No Deficit

Y/N el Observation / Inst Med. (N or C)effects / Side EffectsInst. Fall Prevention Emergency Prepar.Current pain management & effectiveness:Frequency of pain interfering with patients activity or movement:Inst. Disease ProcessDiet. Teaching

Pain Management Teaching to patient / family

Primary Site(s):

0 - Patient has no pain

Safety Precautions/Factors Management ConductedTeach Infant / Childcare

Patient's pain goal:

Intensity 0 1 2 3 4 5 6 7 8 9 10

2 - Less often than daily

Peg / GT Tube Site Care

Low High

Tracheostomy Care Suctioning

3 - Daily, but not constantly

Progress toward pain goal:

TECHNIQUES USED

4 - All of the time

Universal Precautions/ Handwashing Tech. followed

No deficit / Pain

Aseptic Tech.used / Infection Control followed

SKILLED INTERVENTION - TEACHING - Pt. RESPONSEQuality Control of Glucometer Performedas per Agency P & P on:Glucometer Calib. on:Soiled Dressings Double BaggedSharps Discarded Inside Sharps Container

INFUSION / IV SITE:IV Tubing ChangeCap ChangeCentral Line Dressing ChangeIV Site Dressing ChangeIV Site ChangeInfusion by PumpInfusion Med:Infusion Rate:

OTHER PROGRESS TOWARDS GOALS:

PLAN FOR NEXT VISIT:Comments:Infusion Well Tol. by Pt.

PT / S.O. / CG verbalized understanding of inst. given Patient unable to perform own W/C due to:PT / S.O. / CG able to return correct demonstration of Tech. / procedure Inst. on

PT C MOTCARE COORDINATION: Physician SNMSWST

Other:

NURSE SIGNATURE / PRINT NAME DATERN / LPN

/ /Signature / Date -Complete TIME OUT (above) prior to signing below (circle title)

INTERVENTIONS / INSTRUCTIONS

PAIN / FALL MANAGEMENT

Denote Location / Size of Wounds /Measure Ext. Edema Bil.

# 1 #4#2 # 3lengthWidthDepthDrainageTunnelingOdorSurr TissueEdemaStoma

PT ID PERFORMED VIA NAME, DOB, AND ADDRESS BEFORE SERVICE PROVIDED

SUPPLIES USED:MEDICATION STATUS No Change Order Obtained:

Reviewed / Revised with patient / client involvement.CARE PLAN: Outcome achievedPRN Order Obtained:

No S.O. or C/G able / willing for Inj. Adm. at this timeNo S.O. or C/G able / willing for wound care at this time.

DISCHARGE PLANNING DISCUSSED? Yes No N/A

Treatment well tolerated by Patient

Other:

Verification of Medication Performed Prior to Admin.

Verification of Procedure Performed

Patient's Safety Goal

SG

SG

SG

SG

SGSG

Acute episodes of hyper/hypoglycemia yield unsafe ambulation

Dyspnea on minimal exertion Bed / Chair bound

YesClient is at risk for falls no Fall assessment conductedyes N/APotential for falls has:Potential for falls: 0 1 2 3 4 5 6 7 8 9 10

decreasedIncreased SG

Compliant with fall prevention plan: Yes No N/A

Fire Prevention followed SG

SG

www.pnsystem.com 305.818.5940

No Deficit

SKINWarm DryCold ClammyJaundice Pallor CyanosisTurgor Hydration

Integrity

Rash Itching DiscolorationDecubitus Wound Ulcer

Tube Insertion SiteOther

No Deficit

ENDOCRINEWeakness Fatigue Tired No Deficit

Sign/Symptoms of Polydipsia PolyphagiaSign/Symptoms of Hyperglycemia Hypoglycemia

Other

HHA

Amount:Via:Flushing:Appetite: Good Fair Poor

DME/SUPPLIES: Gloves Thermometer BP cuff Glucometer Alcohol pads 4x4 Sharp container Other:

Unable to drive

1- Pain does not interfere with activity or movement

SQ Injection: Site:Site:

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PN SystemBlanco

PN SystemBlanco

PN SystemBlanco

PN SystemBlanco

PN SystemBlanco

PSYCHIATRIC NURSE PROGRESS NOTEPATIENT'S EMPLOYEEDATEPATIENT'S NAME

MO, DAY YR. NUMBER INITIALSNUMBERFIRST NAMELAST NAME

NURSING VISIT CODERV - ROUTINE VISITEV - EMERGENCY VISIT

HOMEBOUND DUE TO: ISKILLED NURSING SERVICES

PATIENT/FAMILY TEACHINGS:OBSERVATIONS/MONITORINGIRREGREGAPVITAL SIGNS: BP MEDICATION REGIME

RESPIRATIONSTEMPACTION/SIDE EFFECTS OF: BSRALESLUNGS: CTAS/S DISEASE PROCESS OF:

REGRESSEDSAMEMENTAL STATUS: IMPROVED S/S OF COMPLICATIONS OF:DISORIENTEDCONFUSEDALERTEXTRAPYRAMIDAL SYMPTOMSABSENTHALLUCINATIONS/DELUSIONS: PRESENT

ABSENTSUICIDAL TENDENCIES: PRESENT SAFETY MEASURESABSENTEXTRAPYRAMIDAL SX- PRESENT

RELAXATION TECHNIQUESPERSONPLACEORIENTED: TIMEPOORFAIRINSIGHT PT/FAMILY: GOOD NUTRITION THERAPY PROVIDED

REGRESSEDSAMEMOOD/AFFECT: IMPROVEDDIET SUPPORTIVECOMBATIVEDEPRESSEDFLAT

NEGATIVEANXIOUSAGITATED PROPER FLUID INTAKE REALITYREGRESSEDSAMECOMMUNICATION: IMPROVED

SOCIALIZATION:AIDE SUPERVISORY VISIT YESSOMATIZATION: N O

FAIR POORVENTILATES FEELINGS: GOOD PATIENT SATISFIED WITH CARERAPPORT:

AIDE FOLLOWING CARE PLANREGRESSEDSAMEPATIENT with FAMILY: IMPROVEDSAME REGRESSEDFAMILY with PATIENT: IMPROVED CARE PLAN UPDATEDSAME REGRESSEDIMPROVEDPATIENT with RN: TIMES PER WEEKAIDE NEEDED

REGRESSEDSAMEFAMILY with RN: IMPROVEDNUTRITION STATUS:

SPECIFIC MEDICAL TREATMENTS/TEACHINGSDECREASEDSAMEIMPROVEDAPP

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